A nurse is assessing a postpartum client for signs of infection.
Which of the following should the nurse report immediately? A) Lochia with clots.
Lochia with clots.
Fundus firmness
Abdominal distension
Breast tenderness.
Temperature greater than 38°C for more than 48 hours.
The Correct Answer is E
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours. This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention. A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots. However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding. A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside. However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
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Correct Answer is B
Explanation
The correct answer is choice B. Palpate fundus.The nurse should first assess the tone of the uterus by palpating the fundus, as uterine atony is the most common cause of postpartum hemorrhage.
If the uterus is boggy or soft, the nurse should massage it gently until it becomes firm and contracts.
This will help control the bleeding from the placental site.
Choice A is wrong because assessing vital signs is not the first priority in this situation.Vital signs may not reflect the severity of blood loss until late in the process of hemorrhage.
The nurse should monitor vital signs after ensuring that the uterus is contracted.
Choice C is wrong because administering oxytocin as prescribed is not the first action the nurse should take.
Oxytocin is a medication that stimulates uterine contractions and reduces bleeding, but it should be given
Correct Answer is B
Explanation
The correct answer is B. Palpate fundus.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
A. Assess vital signs.
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
C. Administer oxytocin as prescribed.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
D. Check perineal pad.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
Checking perineal pad can help estimate the amount of blood loss, but it does not address the cause of bleeding.
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